Emerging Trends and Alerts

DEA Temporarily Bans Synthetic Opioid U-47700 ("Pink"), Linked to Nearly 50 Deaths

Posted on November 15, 2016

The U.S. Drug Enforcement Administration (DEA) has temporarily classified U-47700, nicknamed "Pink," a schedule I drug, which means it has a high potential for abuse and no approved medical use. Since last year, this dangerous synthetic opioid has been linked with at least 46 confirmed deaths—31 in New York and 10 in North Carolina. Law enforcement agencies have seized the drug in powder form and as counterfeit tablets that mimic pharmaceutical opioids. Earlier this year, law enforcement in Ohio seized 500 pills resembling a manufacturer's oxycodone immediate-release tablets. However, laboratory analysis confirmed that they contained Pink.

Pink belongs to a family of deadly synthetic opioids far more potent than morphine. It is usually imported to the United States, mainly from illicit labs in China. The drug can be toxic—even in small doses. It is typically taken by itself or combined with other drugs such as heroin and fentanyl.

Pink's name comes from the pinkish hue of the powder. It has been available for purchase over the internet and is misleadingly marketed as a "research chemical." Labels that state "not for human consumption" or "for research purposes only" are likely used in an effort to avoid legal restriction.

For more information, see the DEA news release on its scheduling of Pink.

DEA Issues Nationwide Warning on Carfentanil

Posted on September 23, 2016

The Drug Enforcement Administration (DEA) has issued a nationwide warning to the public and law enforcement about human use of the potent animal opioid sedative carfentanil, one of the strongest opioids available. Carfentanil, a fentanyl analog with a potency approximately 10,000 times that of morphine, has been linked to a significant number of overdose deaths nationwide. It is used as a sedative or in general anesthesia for large animals, including elephants, but is not approved for use in humans. https://www.dea.gov/divisions/hq/2016/hq092216.shtml

In August 2016, NIDA posted carfentanil warnings by authorities in Ohio and Florida. As with many fentanyl analogs, it is likely that carfentanil is being added to mixtures of heroin and other street drugs, but it is not known how often carfentanil is being added to or substituted for other opioids in street drugs, underscoring its danger. More information can be seen under the August 23rd, 2016 posting below.

Fentanyl-Related Overdoses Prompt Alert from CDC

Posted on August 26, 2016

The Centers for Disease Control and Prevention (CDC) has released an alert to public health departments, health care professionals, first responders, and others through its Health Alert Network about the increase in fentanyl-related overdoses and deaths in many parts of the country. Fentanyl is an extremely potent synthetic opioid—50 times stronger than heroin. Traditionally, fentanyl and analogs such as carfentanil have been mixed with powder heroin. Fentanyl-laced heroin has been linked to a surge of overdoses in Indiana and Ohio in late August, 2016. Fentanyl and related compounds are also being found in counterfeit pills made to look like prescription pain relievers and sedatives (e.g., OxyContin^®, Xanax^®, Norco^®). These counterfeit pills are also the subject of a recent Drug Enforcement Administration alert.

Those who use heroin or prescription drugs laced with fentanyl are at much higher risk of overdose and death. When emergency personnel are able to respond in time, they sometimes need multiple doses of naloxone to reverse fentanyl overdoses.

Alert Issued in Ohio for Human Use of Animal Sedative Carfentanil, with Cases Also Seen in Florida

Posted on August 23, 2016

Officials in the Cincinnati area (Cuyahoga County) have issued an alert about human use of the potent animal opioid sedative carfentanil, one of the strongest opioids on the market, with a potency approximately 10,000 times that of morphine and 100 times that of fentanyl. Carfentanil is an analog of the synthetic opioid analgesic fentanyl and is used as a sedative or in general anesthesia for large animals, including elephants. Side effects of fentanyl analogs in humans are similar to those of fentanyl itself, which include itching, nausea, and potentially serious respiratory depression, which can be life-threatening. Officials in Ohio have noted a high number of overdoses in a short period of time that are suspected to be from carfentanil. NIDA’s National Drug Early Warning System (NDEWS) reports several confirmed deaths in Akron and Columbus, and numerous seizures of the drug throughout Ohio. Read the public health warning from Cuyahoga County, Ohio.

In Florida (Manatee County), there was a recent seizure of carfentanil and a coincidental increase in overdoses and deaths. While more than a dozen fentanyl analogs are commonly flagged in postmortem testing in many states, it is difficult to assess how commonly carfentanil is being abused because states have few reference materials on this drug and few labs are equipped to test for it. The forensic toxicology laboratory researchers at the University of Florida are currently developing a new assay for the identification of carfentanil and will soon start including it in postmortem overdose death testing. Laboratory personnel are being warned about the potency of the drug and are advised to handle it with great care. Naloxone (Narcan®) should be available in the case of accidental exposure.

As with many fentanyl analogs, it is likely that carfentanil is being added to mixtures of heroin and other street drugs. Currently, it is unclear how often carfentanil is being added to or substituted for other opioids in street drugs, underscoring the risks of using illegal drugs.

More information can be found at the National Library of Medicine's Pubchem database – carfentanil.

Fake Prescription Drugs Laced with Fentanyl

Updated July 28, 2016

The Drug Enforcement Administration reports that the United States is in the midst of a fentanyl crisis, as traffickers are flooding the drug market with counterfeit prescription drugs containing fentanyl, an extremely powerful opioid. These pills, which look like legitimate prescription pain relievers or sedatives, are causing large numbers of fatal overdoses in many parts of the country. Because of its high potency, fentanyl is deadly in very small doses; it is even hazardous for law enforcement, as a lethal dose can be accidentally inhaled or absorbed through skin contact. For more information, see the DEA report - Counterfeit Prescription Pills Containing Fentanyls: A Global Threat (PDF, 3.1MB).

Original Alert

Media reports and official alerts in several U.S. communities (including Sacramento, CA and most recently, Carroll County, MD) are warning of counterfeit pain and anxiety medications that actually contain fentanyl, an extremely powerful, potentially deadly opioid. The pills, which are disguised as common prescription drugs like Norco (hydrocodone), Percocet (oxycodone), and Xanax (alprazolam), are responsible for a growing number of overdose deaths and non-fatal overdoses around the country. Fentanyl is 25 to 50 times stronger than heroin, so even a small amount can cause an overdose. (The Drug Enforcement Administration reports that some of these pills are manufactured in China and smuggled into the U.S. via Mexican drug cartels.)

The fake pills are much cheaper than the real versions. The public should be aware that drugs obtained on the street, even though they look like a real prescription pharmaceutical, may be deadly. It is always unsafe to take a prescription drug unless it comes from your own prescription and is dispensed by a reputable pharmacy.

Synthetic Cannabinoid Advisory in New York City

Posted on July 16, 2016

On July 14, 2016, New York City health officials issued an advisory about an increase in adverse events and emergency department visits related to synthetic cannabinoids (K2/Spice). From July 11 through July 13, 130 people were taken to emergency rooms after suspected ingestion of these drugs, which are sold under many street names including Geeked Up, Smacked, Scooby Snax, Green Giant, Red Giant, M. Bad Guy, Trippy, Ice Dragon, AK-47, and Kick. Synthetic cannabinoids, sometimes called "fake weed" or "herbal incense," are chemically related to THC, the active ingredient in marijuana, but they may be much more powerful. Their effects can be unpredictable and have caused death in some cases. In recent cases in New York City, some users' overdoses resemble opioid overdoses, including lethargy and suppression of breathing; in other cases they have exhibited agitated and violent behavior. The increase in emergency room admissions might indicate that the K2/Spice products circulating in the New York City area might be laced with other toxic chemicals. View Advisory (PDF, 61KB)

For more information on synthetic cannabinoids, see DrugFacts: K2/Spice ("Synthetic Marijuana")

Loperamide Misuse/Abuse

Posted on June 09, 2016

Loperamide is an over-the-counter anti-diarrheal medication that is available in tablet, capsule, or liquid form under brand names such as Imodium, Kaopectate 1-D, Maalox Anti-Diarrheal, and Pepto Diarrhea Control. Because it acts at mu-opioid receptors, which regulate movement in the intestinal tract, it is an opioid medication, and there are reports of its being misused by drug users to stave off opioid withdrawal or possibly even to get high.

Misuse of loperamide has been reported since 2003; it is not common, but it has been reported all over the country. Nationwide, the number of calls to poison centers involving the intentional abuse or misuse of loperamide increased from 87 in 2010 to 190 in 2014 (AAPCC annual reports; http://www.aapcc.org/annual-reports/).

Effects of Loperamide

When taken as recommended, loperamide is designed not to enter the brain; but instructions available on the Internet purport to show how taking loperamide in very high quantities and combining it with other substances may help it produce psychoactive effects that resemble the euphoric effects of other opioids or that mitigate cravings and withdrawal symptoms.

Users’ reports of these effects effects (if any) are conflicting, but physical consequences of loperamide misuse may be severe, including fainting, abdominal pain, constipation, cardiovascular toxicity (including racing heart and even cardiac arrest), pupil dilation, and kidney failure from urinary retention. Anecdotes and case reports indicated that the potential harm is high.

There were also reports of opioid withdrawal symptoms when users stopped taking loperamide, including severe anxiety, vomiting, and diarrhea.

FDA issued a Safety Alert about Loperamide on 6/7/16: Loperamide (Imodium): Drug Safety Communication - Serious Heart Problems With High Doses From Abuse and Misuse

More information on loperamide is also availabe from the National Drug Early Warning System (NDEWS).

Surge in Fentanyl Overdose Deaths

Posted on July 09, 2015

A surge in overdose deaths related to fentanyl, an opioid 30 to 50 times more potent than heroin, has prompted Baltimore health officials to launch a public health campaign to raise awareness among drug users. Hundreds of people have overdosed on fentanyl across the nation since 2013, often as a result of using heroin that has been laced with the much stronger substance. A quarter of drug overdose deaths in Maryland now involve fentanyl, up from 4 percent in 2013. Opioid overdose can stop a person's respiration, and fentanyl can have this effect very quickly. Other parts of the country such as Detroit and surrounding suburbs are also seeing major surges in fentanyl use and fentanyl-related deaths. In some cases users are unknowingly taking fentanyl in what they believe to be pure heroin, but a growing number of opioid users are deliberately taking fentanyl.

Fentanyl and other opioid overdoses can be reversed if the drug naloxone (Narcan) is administered promptly. In a growing number of states, naloxone is being distributed to injection drug users and other laypersons to use in the event of overdose. For example, Baltimore's Staying Alive Drug Overdose Prevention and Response plan issues naloxone and training in its use.

Increasing Overdoses From Synthetic Cannabinoids (“Spice,” "K2,” etc.) in Several States

Updated May 08, 2015

Recent surges in hospitalizations and calls to poison control centers linked to consumption of synthetic cannabinoid products--sold under brand names like “Spice,” “K2,” "No More Mr. Nice Guy," and others--are being reported in several southern and northeastern U.S. states and have prompted officials to issue health warnings. After a surge in synthetic cannabinoid exposures and poison center calls in April and May, 2015, the Maryland Poison Center issued an urgent notice about the dangers of these drugs. New York Governor Andrew Cuomo issued an alert after more than 160 patients were hospitalized following synthetic cannabinoid use in under two weeks in mid April, 2015.

Synthetic cannabinoids are chemically related to THC, the active ingredient in marijuana, and are sometimes called “synthetic marijuana” or “legal marijuana,” but actually the effects can be considerably more powerful and more dangerous than marijuana. Users can experience anxiety and agitation, nausea and vomiting, high blood pressure, shaking and seizures, hallucinations and paranoia, and they may act violently.

The Maryland notice lists several chemical compounds in materials from crime labs, including MAB-/AB-CHMINACA, FUBINACA, FUB-PB-22, and XLR11. Besides the brand names above, the New York State health alert lists other common names: Blonde, Summit, Standard, Blaze, Red Dawn X, Citron, Green Giant, Smacked, Wicked X, AK-47; recent reports have involved products with the names Geeked Up, Ninja, Caution, Red Giant, and Keisha Kole.

For more information on synthetic cannabinoids, see DrugFacts: K2/Spice ("Synthetic Marijuana")

U.S. and British Columbia Issue Alerts on Fentanyl

Updated March 18, 2015

The U.S. Drug Enforcement Agency (DEA) has issued a nationwide alert about the dangers of fentanyl and related compounds (fentanyl analogues). Fentanyl, an opioid that is 50-100 times more powerful than morphine, is both abused on its own and commonly added to heroin to increase its potency. Fentanyl and fentanyl-laced heroin have been a concern for over a decade and have caused numerous overdose deaths among injection drug users in several U.S. cities.

Heroin is not the only drug that can be laced with fentanyl, however. Officials in Vancouver, British Columbia, Canada, recently issued public warnings about a wide range of fentanyl-laced drugs causing overdose deaths among users. They warn that fentanyl is now being concealed in non-injection drugs, including oxycodone and various "party drugs" in powder or pill form, as well as in marijuana (although no deaths have been confirmed from fentanyl-laced marijuana). Because of this new threat, British Columbia officials are urging all recreational drug users to "know their source."

HIV Outbreak in Indiana Linked to Abuse of Opana

Posted on February 27, 2015

Health officials in Indiana have announced a fast-spreading outbreak of new HIV cases in the southeastern portion of the state that are linked to injection drug abuse of the powerful prescription opioid painkiller Opana. Injecting drugs and sharing injection equipment is one of the main routes of transmitting HIV. Also, a few new HIV cases in southeastern Indiana were transmitted sexually.

Officials advise that people in southeastern Indiana who have engaged in needle sharing or unprotected sex should get tested for HIV and then re-tested after 2-3 months, as HIV may not appear on tests immediately when the virus is contracted. To reduce risk of contracting HIV, avoid injection drug use, sharing or re-using needles, and having unprotected sex or sex with commercial sex workers.

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